3/26/2015 Ebola: Past, Present, & Future Janet A. Jokela, MD, - PDF document

3/26/2015 Ebola: Past, Present, & Future Janet A. Jokela, MD, MPH, FACP, FIDSA Head, Department of Medicine, University of Illinois at Urbana ‐ Champaign Governor, ACP Downstate Region Illinois Chapter April 2015: Alaska ACP & AKOMA Meeting No financial or other conflicts of interest 2 Objectives  List features of the Ebola virus & Ebola virus disease  Describe the current Ebola outbreak in West Africa  Describe infection control measures and preparedness efforts 3 1

3/26/2015 Patient  45 year old man presented with abdominal pain, dizziness, nausea, headache  T100.1°F  Nasal congestion, abdominal tenderness  CT head, abdomen/pelvis: no acute disease  WBC 3.08, platelets 92, glucose 180, creatinine 1.41, AST 94 (normal < 34)  T 103.2°F  T 101.2°F  Discharged: sinusitis & abdominal pain; acetaminophen 4 Three days later…  Returned with diarrhea, abdominal pain, fever  Admitted to the hospital  12 hours later: explosive diarrhea, projectile vomiting  Day #2: too weak to use bedside commode, transferred to ICU  Day #3: diagnosed with Ebola  Day #11: dies from Ebola 5 Photo of Thomas Eric Duncan thescoopblog.dallasnews.com 2

3/26/2015 Calendar of Ebola Patient Duncan course. http://www.nytimes.com/interactive/2014/07/ 31/world/africa/ebola-virus-outbreak-qa.html Past…  List features of the Ebola virus & Ebola virus disease  Describe the current Ebola outbreak in West Africa  Describe infection control measures and preparedness efforts 8 Ebola Virus • Ebola Virus Disease (EVD) • Causes severe illness with 50%-90% mortality • First discovered in 1976 • Democratic Republic of Congo • Sporadic outbreaks • 36% involved <10 people • Only 1 has involved more than 450 people cdc.gov 9 3

3/26/2015 Ebola Virus • ssRNA • Filoviridae , genus Ebolavirus • Five species: • Zaire, Sudan, Ta ï Forest, Bundibugyo; Reston • Reservoirs in Nature – Fruit bats, other? • Disease: Humans, nonhuman primates (gorillas, chimpanzees, monkeys) cdc.gov 10 11 Transmission  Direct contact body fluids • Blood, urine, diarrhea, vomit, semen • Deceased  Medical environment/waste • e.g., syringes  “Bushmeat”  21 ‐ day incubation cdc.gov 12 4

3/26/2015 Signs/Symptoms  Appear 2 ‐ 21 days after exposure Fever higher than 101.5 ○ F • • Severe headache • Muscle pain • Weakness • Diarrhea • Vomiting • Abdominal pain • Unexplained bleeding or bruising cdc.gov 13 Clinical Timeline CLINICAL FEATURES OF EBOLA VIRUS DISEASE Chart from New England Journal of Medicine Chertow DS et al. N Engl J Med 2014;371:2054 ‐ 2057. 14 Calendar of Ebola Patient Duncan course. http://www.nytimes.com/interactive/2014/07/ 31/world/africa/ebola-virus-outbreak-qa.html 5

3/26/2015 Calendar of Ebola Patient Duncan course. http://www.nytimes.com/interactive/2014/07/ 31/world/africa/ebola-virus-outbreak-qa.html Calendar of Ebola Patient Duncan course. http://www.nytimes.com/interactive/2014/07/ 31/world/africa/ebola-virus-outbreak-qa.html Clinical findings  Fluid losses: 5 ‐ 10 L/day  Hypovolemia • Despite weight gains 15 ‐ 20 kg  Electrolyte imbalance • arrhythmias  Malnutrition  Virus detected: blood, urine, vomitus, stool, semen, on skin • Environmental testing (Emory): no virus Lyon GM, et al. NEJM, 12/18/2014 18 6

3/26/2015 Graph from: Lyon GM, et al. NEJM, 12/18/2014 Unexpected findings: Emory  Point of care lab vs. hospital lab  Shipping commercial carriers  Local water authority • Bleach • Autoclaving waste  Media  Pizza Lyon GM, et al. NEJM, 12/18/2014 fastpizzamountainview.com, scoopnest.com 20 Environment  Six hours (saliva, blood, fecal material, urine, semen)  Stable longer: if dark or cold, moist  Bodies: up to a week  Disinfected by 0.05% bleach cdc.gov 21 7

3/26/2015 Clinical course  Age (Sierra Leone) • Under 21 years—57% fatality rate • Over 45—94% fatality rate  Antibodies • Monoclonal: Zmapp • From survivors Schieffelin JS, et al. NEJM, 11/27/2014 22 Diagnosis & Treatment  Testing performed via CDC/Public Health  No vaccine or medication proven effective  Only treatment is supportive care 23 Present…  List features of the Ebola virus & Ebola virus disease  Describe the current Ebola outbreak in West Africa  Describe infection control measures and preparedness efforts 24 8

3/26/2015 Moving Target… jbblog.flopro.taco-hvac.com 25 Ebola Outbreak 2014 ‐ 2015  Persistent transmission only in Sierra Leone & Guinea • Liberia: last Ebola patient sent home 3/6/2015  As of March 11, 2015 • 24,385 total cases • 10,019 deaths  In the US • 2 cases acquired here—recovered • 8 imported cases—two deaths cdc.gov 26 Graph – how many people have been Infected in Africa? NYTimes, Feb. 17, 2015 9

3/26/2015 Graph of new patients each week: Liberia, Sierra Leone, Guinea NYTimes, 3/11/2015 http://www.nytimes.com/ interactive/2014/07/31/world/ africa/ebola ‐ virus ‐ outbreak ‐ qa.html Map of Cases of Ebola Outside of West Africa NYTimes, November 5, 2014 http://www.nytimes.com/interactiv e/2014/07/31/world/africa/ebo la-virus-outbreak-qa.html Patients diagnosed in U.S.  Sept. 30—first patient diagnosed Dallas (dies Oct. 8)  Oct. 10—nurse diagnosed (d/c 10/24)  Oct. 15—second nurse diagnosed (d/c 10/28)  Oct. 23—medical worker diagnosed NYC 30 10

3/26/2015 The Opinion Pages: Room for Debate NYTimes, October 2, 2014 Multi ‐ pronged effort kiimblecharting.tumblr.com NYTimes photo of young Girl on ground with crowd And police watching from Across the street 11

3/26/2015 Craig Spencer, MD “Failing to stop the epidemic at its source threatens everyone” Spencer C, NEJM, 2/25/2015 34 Present…  List features of the Ebola virus & Ebola virus disease  Describe the current Ebola outbreak in West Africa  Describe infection control measures and preparedness efforts 35 Triage  Travel history  Private room cdc.gov 36 12

3/26/2015 Prevention Measures  Staff • Regular practice • Limit number of staff entering the patient room Dedicated clinical care team (inpatient) • • Post an Entry Log outside of patient room • Properly don, doff, and dispose of PPE • Perform hand hygiene diligently  Visitors • No visitors in the patient room cdc.gov 37 13

3/26/2015 Biocontainment Units  Emory  Omaha, NE  NIH  Missoula, MT 41 Special units  Patient care rooms • Anteroom • Autoclave • Point ‐ of ‐ care lab  Nebraska: 5 rooms, 2 beds each 42 14

3/26/2015 Staff  21 RN team • Routine, ongoing training; volunteers  Respiratory therapists, patient care technicians  Day shift: 6 staff members (at least 3 RN’s) • Autoclaver • “Doffer” • Bedside nurse always with patient  Four hours at a time medscape.com 43 In the patient room  Anytime staff member has contact with patient, or fluids: • outer gloves removed, middle layer bleach wiped, replace outer gloves  Every night: • Staff clean room (not housekeeping) • Every surface bleach wiped • Separate mop buckets each area (nurse’s station, patient room, hallway) • Mop heads changed 44 Personal Protective Equipment  Surgical boot covers (knee high)  Impermeable gown  Hood  Gloves: three pairs  N ‐ 95 mask  Face shield  Apron (for specific procedures, then removed immediately) 45 15

3/26/2015 Future…  What are the other current issues and concerns? 46 Questions  Does the infectious dose of virus depend upon how it enters the body?  Does the length of the incubation period depend upon how the person was infected?  Optimal decontaminants?  Economic and social impact?  Etc… 47 IOM Research Priorities  PPE training  Supply chain optimization  Standards for PPE apparel/equipment  Developing a framework for evaluating the system in which PPE is embedded  Compliance with PPE use  Healthcare worker fatigue  Socializing in the workplace & with family 2014 48 16

3/26/2015 Vaccine  Multiple efforts  Entering final stages of trial in Guinea (03/2015)  Fewer patients: more challenging 49 Recovered Photo from nydailynews.com Showing US President Hugging Dallas nurse after She was released for Ebola Treatment October 24, 2014 or is she?... 50 Washington Post photo Of Nina Pham, Ebola survivor Nina Pham survived Ebola, but she says she has experienced hair loss, body aches and insomnia in the months following her infection. (Smiley N. Pool/Dallas Morning News via AP) March 9, 2015 17

3/26/2015 Post ‐ Ebola Syndrome  Develops within weeks, duration months • Visual problems May progress to blindness • • Fatigue • Myalgias, arthralgias  Pathogenesis unknown  No known treatment 52 Airport Screening  ~125 passengers/day from Guinea, Liberia, Sierra Leone  Since August 2014 exit screening: • 80,000+ passengers: 77+ denied boarding, none with Ebola  Entry screening October 2014: • JFK, Newark, Dulles, Atlanta, O’Hare • Three levels; monitored by local health depts.  Two left without symptoms, diagnosed in U.S. • Dallas patient, NYC patient cdc.gov 53 New PPE http://qz.com/346620/a-wedding-gown- designer-gave-the-ebola-hazmat-suit-a- makeover/ 54 18